Preventive care coverage

Applies to non-grandfathered plans

Requirement overview

All private health plans must cover the costs for preventive care. There can be no copays, deductibles or out-of-pocket fees for in-network preventive services.

Out-of-network preventive care services are not completely covered and can be subject to copays, deductibles or out-of-pocket fees.

Preventive care defined

According to the law, preventive care includes "proven" preventive services as posted by:

• U.S. Preventive Services Task Force (services rated A or B)
• Advisory Committee on Immunization Practices 
• Health Resources and Services Administration

Visit healthcare.gov for a list of covered preventive services.

Certain prescription and over-the-counter (OTC) drugs must now be covered at 100% under the medical plan, even if the member is not enrolled in a pharmacy benefit.

What Priority Health is doing

• All of our health plans already cover preventive care services. See our Preventive Health Care Guidelines for a list of covered services.
• Starting 09/23/2010, in-network preventive care services will be covered at 100% for non-grandfathered plans upon renewal.
• Grandfathered plans will continue to have preventive services covered at their current benefit level.
• We added the 10 new categories of service required by the three agencies to our Preventive Health Care Guidelines.
• OTC drugs considered preventive care will require a prescription.

What you need to do

• Grandfathered plans don't have to cover preventive care at 100%.
• Non-grandfathered plans will need to choose a 100% preventive care rider upon their renewal.
• Our sales team will work with self-funded employers that may need to modify their preventive care benefit to include preventive care coverage without imposing cost sharing requirements.